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APPLiCATiONiFOR PERMIT ` . ;HEALTH DISTRICT S .�saN JopaurNocA� l Zt 1 k hiAZe1'rON AV�_;;ST1CTDiV, CA .No 160 hone {209) 466-6781 Telephone DA.TE ISSUED . 1 YEA RFROM PERMIT EXPIRES Triplicate) l+cation is (Complete in work Regulations of the San Joaquin ' � for a permit to construct andlu�A and the Rue and�R 9escr+bed This app ii co for wail!p K Ordinance No.ss4g for sewage or No gpplicatian is rierebY made to the San Joaquin Local Health Distnc Compliance with-San Joaquin County PN1 made in comp t , .°4. v � Lot Size £ Local Health District. - 4 Cit 4/ ! k Phone 11 Job Address 'Address phone ( Owner's Name - License No. Address r DESTRUCTION Contractor WELL REPLACEMENT ❑ OTHER ,4. NEW WELL ❑ SYSTEM REPAIR Q PROP. LiNE TYPE OF WELL/PUMP: T DISPOSAL FLD.� PUMP INSTALL ATION Q PITS/SUMPS 4 � SEWER LiNES 1� .� OTHER WELL� AGRICULTURE WELL ! DISTANCE TO NEAREST: SEPTIC TANK*- AREA CONSTRUCTION SPECIFICATIONS r II FOUNDATION pia. of Well Casing TYPE OF WELL PROBL, E INTENDED USE ❑ Manteca Dia. of Well.Excavation gpecifications ❑ Open Bottom Type of Cas`irig Type of Grout (] Industrial ❑Tracy' X i] Gravel Pack Depth of Grout Seal ❑ Domestic/Private ❑ Delta'� ' ❑ Other Surface Seal installed by ❑ Public ._Approx Depth r [_3 Eastern . L ; State Work Done t R [} irrigation + _ 1 Repair Work Done ❑ Type of Pump �� Sealing Material•(top 50,) i Well Destruction ❑ Well Diameter �— Filler Material (Below,50'1 DESTRUCTION DLit system permitted if public sewer is Depth REPAiRIADDiTVON ❑ available within 200 feet.) + ({ k ' TYPE OF SEPTIC WORK: i NEW INSTALLATION ❑ 4 Commercial— Other��. 3 ) Residence ) ' Installation will serve: Water table depth Number of bedrooms�J r Number of living units: No. Compartments r Character of Soil to a depth of 3 feet: capacity-_— 13 Type/Mfg j Method of Disposal SEPTIC TANK �_Foundation�Pr9perty PKG. TREATMENT PLT. ❑ Well _ Distance to nearest: 1 1Total length!size l Property Line ❑ No. & Length of lines # Foundatibn LEACHING LiNE stance to nearest: Well FiLTER BED ❑ Di1 Number Ilk Size Property Line ❑ Depth Foundation� SEEPAGE PiTS Well - SUMPS ❑ Distance to nearest: . and PONDS ❑ i 1�'1 this application and that the work will be done in accordance with San Joaquin county ordinances, state laws- DISPOSAL1 shall not I hereby certify that I have prepared j€ rules and regulations of_the San Joaquin ocal rtif'+ase the foNorwing: "l c rt�fy that in the performance of the work for which this permit is issued,ractin Home owner or licensed agent's signature h this permit is issued,I shall employ pareons subject to workman's compensa r as to become subject to workman's co Cppnsation.laws of California."_ Contractor's hiring or sub contracting mpenature ploy any person in such manna performance of the work for which the following:" rt, that in the Pe cert tion laws California. late drawing on r verse side. Ct,- r.r I i d in ction . Co ° ;pate: !: he applican call for al e4 �.-c- Title: Signe _.............. � "'"" FIT Area USE ONLY Area I pate Jam, Date i Application Accepted by Final Inspection by Data_��- Pit or Grout inspection by .^^.:-'.-, ".: ... Tracy° 83',6385 `AtlditionaT'Cbmments: ❑ Manteca t 823-7104 �" P.O. Box 2009, Stk., CA 95201 ❑ Stk 466 67$1 ❑ Lodi 369-3621Ave., ._ Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton PERMIT'ND. RECEIVER BY DATE AMOUNT RFMITTED ` FEE AMOUNT DUE �� •�7��* i INFO r c� + EH 13-24(REV. EH 14-26